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Traumatic Brain Injury Claims Assessing Claims, Negotiating Settlements, and Effectively Using Witnesses Today’s faculty features: 1pm Eastern | 12pm Central | 11am Mountain | 10am Pacific The audio portion of the conference may be accessed via the telephone or by using your computer's speakers. Please refer to the instructions emailed to registrants for additional information. If you have any questions, please contact Customer Service at 1-800-926-7926 ext. 10. FRIDAY, NOVEMBER 9, 2012 Presenting a live 90-minute webinar with interactive Q&A Dr. Glenn T. Goodwin, Consulting Neuropsychologist, Edmonds, Wash. Paul Zukerberg, Founder, Zukerberg Law Center, Washington, D.C. John Jerry Glas, Partner, Deutsch, Kerrigan & Stiles, New Orleans Dr. Matthew J. DeGaetano, Whiplash & Brain Traumatology Consultant, Personal Injury Institute, Lewisville, Texas

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Page 1: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Traumatic Brain Injury Claims Assessing Claims, Negotiating Settlements, and Effectively Using Witnesses

Today’s faculty features:

1pm Eastern | 12pm Central | 11am Mountain | 10am Pacific

The audio portion of the conference may be accessed via the telephone or by using your computer's

speakers. Please refer to the instructions emailed to registrants for additional information. If you

have any questions, please contact Customer Service at 1-800-926-7926 ext. 10.

FRIDAY, NOVEMBER 9, 2012

Presenting a live 90-minute webinar with interactive Q&A

Dr. Glenn T. Goodwin, Consulting Neuropsychologist, Edmonds, Wash.

Paul Zukerberg, Founder, Zukerberg Law Center, Washington, D.C.

John Jerry Glas, Partner, Deutsch, Kerrigan & Stiles, New Orleans

Dr. Matthew J. DeGaetano, Whiplash & Brain Traumatology Consultant, Personal Injury Institute, Lewisville, Texas

Page 2: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Sound Quality

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For CLE purposes, please let us know how many people are listening at your

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Page 4: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

NEUROPSYCHOLOGICAL CONSULTATION

IN TRAUMATIC BRAIN INJURY CASES

Glenn T. Goodwin, PhD, DABFE

gtgphd.com

Page 5: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

What you end up believing depends on what you hear and who you hear it from.

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Page 6: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Traumatic Brain Injury (TBI)

A spectrum of injury events along a

continuum Mild concussive syndromes

Mild TBI

Prolonged or irreversible coma

Severe TBI gtgphd.com

6

Page 7: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Chronological Process of Evaluation and Treatment

of TBI and Injury related Issues

• Emergency Room Evaluation

• Hospitalization, acute care and rehabilitation

• General Practitioner (postconcussive syndrome)

• Orthopedic Consultation (postconcussive syndrome)

• Chiropractic, Massage (postconcussive syndrome)

• Physical Therapy

• Neurological Consultation (postconcussive

syndrome)

• Neuropsychological Consultation

gtgphd.com

7

Page 8: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Optimum Clinical and Medicolegal Scenario

It is crucial to have the network of treating providers be on the same clinical and research awareness page with their background, training, clinical experience and understanding about TBI.

Experts can be integrated into this process…directly or indirectly.

Develop a solid medical foundation for the brain injury event through convergence of evidence memorialized in medical records and then with an experienced neurologist and/or physiatrist familiar with the current research and in active practice evaluating and treating patients with mild to severe TBI.

(1) An initial neuropsychological consultation to provide an operational diagnostic assessment and clinical blueprint for refining the direction of further care and treatment…an objective evaluation of the effects of this injury event and all the injury related issues. (2) Obtain a final neuropsychological consultation down the road to make more precise estimates regarding the long-term prognosis.

Obtain final assessments from the cognitive rehab providers (speech pathologists, occupational therapists, psychologists), vocational experts and life-care planners.

8

gtgphd.com

Page 9: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

The Task for the Consulting

Neuropsychologist

The starting position should be one of “clinical neutrality”

An opportunity to review and examine the injury issues within the context of all available background information

To determine the probability of specific factors that may be contributing to the persistence of residual symptomatology

Evaluating and bringing probable explanations to the surface and highlighting these issues

gtgphd.com

9

Page 10: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Neuropsychological Issues in Medicolegal Cases of

TBI

Clinical Issues

1. Chronic pain, sleep disturbance, medication effects

2. PTSD, anxiety, depression, adjustment disorder

3. Postconcussive syndrome (PCS)

4. Somatization

5. Premorbid vulnerability

gtgphd.com

10

Page 11: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Neuropsychological Issues in Medicolegal Cases

of TBI

Medicolegal Issues

1. Effects of litigation

2. Secondary Gain

3. Conviction of Disability/Exaggeration

4. Malingering

gtgphd.com

11

Page 12: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Clinical vs. Forensic Neuropsychological

Consultation

Clinical • Patient is the client

• Focus on diagnostics and treatment planning

• Informed consent

• Greater confidentiality

• Usually discoverable as medical records

• Reimbursable under insurance provisions

Forensic • Retained expert

• Referral source is the client

• Focus is on case analysis and expert opinion

• Does not require informed consent

• Limited Confidentiality

• Can be non-discoverable

• Greater accountability

Shared elements: diagnostic interview and testing gtgphd.com

12

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GUIDELINES FOR OPTIMUM

MEDICOLEGAL PRACTICE

gtgphd.com

13

Page 14: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Subjective complaints alone are not a reliable

or valid basis for assessing postconcussive

symptoms and aftereffects of TBI.

gtgphd.com

14

Page 15: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Neuropsychological examination provides

objective analysis and documentation of

neuropsychological symptoms of TBI, other

injury related sequalae and non-injury

related factors.

gtgphd.com

15

Page 16: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Pre-existing conditions and vulnerabilities

are almost always factors that should be

identified and considered in explaining

current functioning after accident or injury

gtgphd.com

16

Page 17: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Neuropsychological examination is standard

practice in helping to verify legitimate

residual neuropsychological symptoms of

TBI and other injury related factors.

Initial neuropsychological examination…documenting the injury

related issues, establishing the initial post injury baseline, providing

a diagnostic blueprint for care and treatment

Pre-settlement follow-up neuropsychological

examination…determining the final prognosis

gtgphd.com

17

Page 18: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

GLENN T. GOODWIN, PHD, DABFE HERITAGE BUILDING

555 DAYTON, SUITE E

EDMONDS, WA 98020

206-663-0816

[email protected]

gtgphd.com

Page 19: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Traumatic Brain Injury Claims A Plaintiff’s Perspective Paul Zukerberg [email protected]

Zukerberg Law Center (202) 232-6400

Washington, DC

Page 20: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Summary

• Client intake

• Quantifying the client’s injury

• How to develop your case for trial

20

Page 21: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Your client intake should always include a TBI screening Factually, was there a blow to the head, or forces sufficient to cause a TBI.

• Does the client report symptoms?

• Look for amnesia (a loss of memory at the time of the injury) - the main indicator of TBI (not loss of consciousness)

• Other TBI check-boxes at intake include reported:

• headache, confusion, dizziness, blurry vision, fatigue, mood and personality changes, concentration issues, vomiting, seizures, slurred speech, weakness or numbness of the extremities, agitation or irritability and impulse control issues.

21

Page 22: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

TBI can be Hidden

Client Fails to Report

• Preoccupied with other injuries or problems

• Ironically, brain injury can effect self-awareness

• Client may not fully realize his injury’s impact on those closest to him

Not in Medical Records

• Physician may lack experience in treating and evaluating patients with TBI

• Never asked to evaluate

• Diagnoses concussion – but recognizes recovery is variable 22

Page 23: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

TBI is a PROCESS

• IMPACT is the event which triggers pathological changes in the client’s brain causing injury

• The damage following a TBI can be immediate - but can also develop over days, weeks, months or even years

• Disruptions to cerebral blood flow, or the alteration of pressure within the skull, can cause secondary damage to the brain which can be greater than the damage from the initial blow.

23

Page 24: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Discount DOI CT Scans

• “Day of Injury” (DOI) CT scans, given in the ER soon after impact, may actually be administered too soon to visualize the impending damage

• In one study, the DOI (day of injury) MRI was read as normal, but the patient was comatose.

• A follow-up MRI was completed 5 days later, which showed the beginnings of signal change.

• But a complete picture of the damage was not seen until a scan 4 years later

24

Page 25: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Quantifying Client’s Damages

• Neuropsychological Testing

• Deficits in cognition, memory, sensory processing, communication, attention and delayed reaction times are common, so is depression and personality changes

• Neuropsychological testing, by a clinical or forensic psychologist, is used to assess the extent of impairment to a particular skill

• Neurodiagnostic tests contain validity scores designed to capture malingering, lack of effort, and exaggeration of symptoms

25

Page 26: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Imagining Studies

• Only captures gross anatomy

• MRI resolution goes down to approximately a millimeter

• When we discuss brain cells, we are talking in microns – a millionth of a meter.

• Changes at the microscopic level, where TBI occurs, cannot be seen at the macroscopic level of our current brain imaging technology

• Diffuse axonal injury (DAI), the most common injury in TBI, cannot be seen with current imaging technology

26

Page 27: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Concussions Can’t be Seen

• CT scans and MRIs cannot detect a concussion

• If anything abnormal does show up on a CT scan or MRI, by definition, you client doesn’t have a concussion.

• He has something much more serious, such as a subdural hematoma or a focal brain lesion.

27

Page 28: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Diffusion Tensor Imaging (“DTI”) accepted under Daubert Test

DTI illustrates the direction of water flow through the fiber tracts of the brain

28

Page 29: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Voxel Based Morphography (“VBM”) is used to illustrate brain volume loss due to cellular death following TBI

29

Page 30: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

SPECT, short for single emission computed tomography can create 3D studies of the brain

SPECT is particularly useful in cases carbon monoxide poisoning cases and other toxic/anoxic brain injuries

30

Page 31: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Investigation

• Check Glascow Coma Score (GCS)

• Both EMS report and Hospital Admission

• Quick measure of consciousness that is now incorporated into ER forms

• Numerous studies have shown that GCS is an accurate prognosticator of cognitive recovery and functional outcome

• 3 test scores: Eye (“E”), Verbal (“V") and Motor Responses (“M”) GCS add them up.

• The lowest possible GCS is 3, representing a deep coma, and the highest is 15, which is a fully conscious person

• Be sure to carefully review statements of witnesses to project GCS at the time of impact

31

Page 32: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

A Legal Odyssey:

Evaluating “Risk” In

Brain Injury Cases

Presented By:

John Jerry Glas

Deutsch, Kerrigan & Stiles, L.L.P.

New Orleans, Louisiana [email protected]

Page 33: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

• Diagnostic Images

Defense

Evaluation

33

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Severity Of Injury

Brain Herniation

Midline Shift

Mass Effect

Edema

Hematoma

35

Page 36: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Classifications

36

Page 37: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Hey Rocky, did you get any

brain damage?

Yo, I don’t see any.

Reporter:

Rocky:

37

Page 38: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Trial # 1:

Hairline Fracture

Trial # 2:

Comminuted & Depressed Fracture

38

Page 39: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Midline Shift No Midline Shift

Trial # 1:

Hairline Fracture

Trial # 2:

Comminuted & Depressed Fracture

39

Page 40: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Trial # 1:

Hairline Fracture

Trial # 2:

Comminuted & Depressed Fracture

Mass Effect No Mass Effect

40

Page 41: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Trial # 1:

Hairline Fracture

Trial # 2:

Comminuted & Depressed Fracture

Hematoma Hematomas

41

Page 42: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

42

Page 43: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

• Diagnostic Images

• Glasgow Coma Scale Scores

Defense

Evaluation

43

Page 44: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Initial Symptoms

• LOC

• GCS < 15

• Seizures

• Vomiting

• Dizziness

• Anger

• Impulsivity

• Headaches

• Loss of Appetite

• Insomnia

• Aphasia

• Slurred Speech

• Drainage of bloody or

clear fluid through

ears or nose

• Weakness in limbs

Initial Symptoms

44

Page 45: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Predictors Of

Outcome

“Within all domains, injury

severity (as measured by

24 h GCS), pre-injury

adaptive abilities (VABS),

and SES were significant

predictors of 30 month

outcomes. . .”

45

Page 46: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Glasgow coma scale

(Adult)

(E) Eye Opening (V) Verbal Response (M) Motor Response

4 = Spontaneous

3 = To Voice

2 = To Pain

1 = None

5 = Normal

Conversation

4 = Disoriented

Conversation

3 = Words, But

Not Coherent

6 = Normal

5 = Localizes

To Pain

4 = Withdraws

To Pain

3 = Decorticate

Posture 2 = No Words,

Only Sounds

1 = None

2 = Decerebrate

1 = None

46

Page 47: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Glasgow coma scale

(Children)

(E) Eye Opening (V) Verbal Response (M) Motor Response

4 = Spontaneous

3 = To Voice

2 = To Pain

1 = None

5 = Coos, Babbles

4 = Irritable Cry

3 = Cries To Pain

6 = Normal

5 = Withdraws

To Touch

4 = Withdraws

To Pain

3 = Abnormal

Flexion

2 = Moans To Pain

1 = None

2 = Abnormal

Extension 1 = None

47

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48

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Severity of Injury

Length of Time of LOC:

Mild: 0 to 30 minutes

Moderate: 30 min to 24 hours

Severe: 24 hours or more

49

Page 50: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Predictors Of

Outcome

For adults, cognitive deficits and

symptoms are common in the

acute stage, and the majority of

studies report recovery for most

within 3-12 months.

Prognosis for Mild Traumatic Brain Injury: Results of the WHO

Collaborating Centre Task Force on Mild Traumatic Brain Injury.

Carroll, L. J., Cassidy, J.D., et al. Journal of Rehabilitation Medicine

2004; suppl. 43: 84-105

50

Page 51: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Predictors Of

Outcome

Cumulative Percent of Head-Injured Subjects Who Returned to Work:

% Returned to Work

Characteristics N 1 mo 6 mo 12 mo 24 mo

GCS

< 8 GCS 93 0% 13% 26% 37%

9-12 GCS 56 4% 44% 56% 64%

13-15 GCS 213 25% 63% 80% 83%

51

Page 52: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Predictors Of

Outcome

Prognosis for Mild Traumatic Brain Injury: Results of the WHO

Collaborating Centre Task Force on Mild Traumatic Brain Injury.

Carroll, L. J., Cassidy, J.D., et al. Journal of Rehabilitation Medicine

2004; suppl. 43: 84-105

Where symptoms persist,

compensation/litigation is a factor,

but there is little consistent

evidence for other predictors.

52

Page 53: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

• Diagnostic Images

• Glasgow Coma Scale Scores

• Neurospychological Testing

Defense

Evaluation

53

Page 54: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

• Impaired Function

• Area of Brain Associated w/ Function

• All Tests That Evaluate That Function

• Details About Tests & Answers

• Applicability of Practice Effect

• Daily Activities Associated With Function

• Other Functions Associated w/ Area of Brain

Deposing

Neuropsychologists

54

Page 55: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

• Impaired Function

• Area of Brain Associated w/ Function

• All Tests That Evaluate That Function

• Details About Tests & Answers

• Applicability of Practice Effect

• Daily Activities Associated With Function

• Other Functions Associated w/ Area of Brain

Deposing

Neuropsychologists

55

Page 56: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

1300 A.D. Jan. 29, 2007

Brain

Cartography

56

Page 57: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Lobes & Lymbic System

57

Page 58: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

• Impaired Function

• Area of Brain Associated w/ Function

• All Tests That Evaluate That Function

• Details About Tests & Answers

• Applicability of Practice Effect

• Daily Activities Associated With Function

• Other Functions Associated w/ Area of Brain

Deposing

Neuropsychologists

58

Page 59: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

• Impaired Function

• Area of Brain Associated w/ Function

• All Tests That Evaluate That Function

• Details About Tests & Answers

• Applicability of Practice Effect

• Daily Activities Associated With Function

• Other Functions Associated w/ Area of Brain

Deposing

Neuropsychologists

59

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• Impaired Function

• Area of Brain Associated w/ Function

• All Tests That Evaluate That Function

• Details About Tests & Answers

• Applicability of Practice Effect

• Daily Activities Associated With Function

• Other Functions Associated w/ Area of Brain

Deposing

Neuropsychologists

61

Page 62: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

Practice Effect Testimony

“Based on the research – and actually one

of the abstracts that Dr. Bell referred to, the

research shows that people with damaged

brains don’t benefit from being tested over

again, and people who are normal do

benefit from being tested again.”

Defense Neuropsychologist Trial Testimony

62

Page 63: Traumatic Brain Injury Claimsmedia.straffordpub.com/products/traumatic-brain-injury... · 2012-11-01 · Traumatic Brain Injury Claims . Assessing Claims, Negotiating Settlements,

• Impaired Function

• Area of Brain Associated w/ Function

• All Tests That Evaluate That Function

• Details About Tests & Answers

• Applicability of Practice Effect

• Daily Activities Associated With Function

• Other Functions Associated w/ Area of Brain

Deposing

Neuropsychologists

63

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• Impaired Function

• Area of Brain Associated w/ Function

• All Tests That Evaluate That Function

• Details About Tests & Answers

• Applicability of Practice Effect

• Daily Activities Associated With Function

• Other Functions Associated w/ Area of Brain

Deposing

Neuropsychologists

64

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Memory

Language

Initiation

Judgment

Impulse Control

Social & Sexual Behavior

Motor Function

Problem Solving

Frontal Lobe

Functions

65

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• Diagnostic Images

• Glasgow Coma Scale Scores

• Neurospychological Testing

• Pre-Morbid Ability

Defense

Evaluation

66

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“Under Goodell’s new policy, all

players will be required to take a

baseline neuropsychological test

– determining cognitive abilities,

memory and motor skills – by the

start of the 2007 season. That

way, when a player has a

concussion, he can be tested to

determine what neurological

changes have taken place.”

Dave Goldberg

AP Football Writer

May 2, 2007

Reprinted in TP-SI

67

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Before After

• Pre-Accident Testing

• School Records

• Standardized Tests

• IQ Tests

• Interests & Hobbies

• Employment

• Post-Accident Testing

• Regression Equations

• Clinical Interviews

Pre-Morbid Ability

68

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“On the Wide Range Achievement Test-3, he obtained a standard score Of 88 on Reading, 64 on Spelling, and 65 on Math. These scores are Significantly lower than expected from his academic history.”

Neuropsychologist’s Report

Example Case # 1

69

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Pre-Morbid Writing

Sample # 1

70

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• Afored (afford)

• Atend (attend)

• Canadate (candidate)

• Canidate (candidate)

• Cailber (caliber)

• Canot (cannot)

• Comment (commitment)

• Dose (does)

• Extermaly (extremely)

• Finialy (finally)

• Totaly (totally)

• Tought (taught)

• Unacepable (unacceptable)

• Voluteer (volunteer)

• Weather (whether)

Pre-Morbid Writing

Sample # 1

71

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• Alabamer (State)

• Bevery Hills (City)

• Brocker (Job)

• Buisenn (Business)

• Jennafer (Wife)

• Jenafer (Wife)

• Luthran (Religion)

• Political Scienece (Degree)

• Politicail Scince (Degree)

Pre-Morbid Job

Applications

72

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Pre-Morbid Admissions

Letter

73

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As a person with dyslexia,

I have never allowed my

handicap to get in the way

of my goals. . .

74

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• Diagnostic Images

• Glasgow Coma Scale Scores

• Neurospychological Testing

• Pre-Morbid Ability

• Malingering

Defense

Evaluation

75

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• Diagnostic Images

• Glasgow Coma Scale Scores

• Neurospychological Testing

• Pre-Morbid Ability

• Malingering

• Moaners & Groaners

Defense

Evaluation

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Scrutiny After

TBI

77

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• Learn All Of Their Opinions

• Learn Stories Behind Each Opinion

• Dissect Anecdotal Stories

• Find Antidotal Stories

• Define Period Of Observation

• Determine Bias Of The Observer

Anecdotal Story

78

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“Normally, he’s good with kids. He has his Grandkids over and one of them spent the night, and he was short tempered. . .”

Plaintiff’s Sister

Anecdotal Story

79

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• Granddaughter dropped off at noon

• Promised to return that night

• Did not return for 24 hours

• Granddaughter was 6 months old

• Wife worked 7:00 a.m. to 3:00 p.m.

• Plaintiff “never lost his temper”

Anecdotal Story

80

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• Granddaughter dropped off at noon

• Promised to return that night

• Did not return for 24 hours

• Granddaughter was 6 months old

• Wife worked 7:00 a.m. to 3:00 p.m.

• Plaintiff “never lost his temper”

Anecdotal Story

81

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A Legal Odyssey:

Evaluating “Risk” In

Brain Injury Cases

Presented By:

John Jerry Glas

Deutsch, Kerrigan & Stiles, L.L.P.

New Orleans, Louisiana [email protected]

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MILD TRAUMATIC BRAIN

INJURIES “MTBI”

Post Concussion Syndrome

Closed Head Trauma

Soft Head Injury

Blunt Head Injury

Post-Head-Trauma Syndrome

84

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Mechanism of Injury

• Mechanism of Injury

• Angular Acceleration The mechanism of the trauma was previously thought to be a shearing of

axons which result from abrupt acceleration and deceleration of brain tissue (784). During a low

speed whiplash injury (7 mph) the head may be accelerated to 9-18 g (87).

• Since the brain is a soft structure, shear strains are created as the outer part of the brain moves at a

different pace than the inner part of the brain. This is intensified as the momentum of the head

changes rapidly in a sagittal direction during a whiplash trauma.

• Ommaya and Hirsch (116) studied the tolerances of primates to whiplash and calculated, by

interpolation, that angular accelerations of 1800 rad/sec2 would result in a cerebral concussion in

man about 50% of the time. They noted, however, that this threshold may very well be as low as

1600 rad/sec2. [Note that in Hypertext, the superscript 2, indicating a number squared, is reduced to

a regular font 2.] As an interesting note, recent crash studies have produced angular accelerations

of volunteers' heads of up to 1000 rad/sec2 in one study (1148) to as high as 1260 rad/sec2 in

another (1175).

• And these are low speed crashes. The most important factors in whiplash-induced concussion are

angular acceleration, flexion/extension tensions in the neck, and intracranial pressure gradients

(787).

85

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300 × 225 - New Study Confirms Brain Changes From

Single Mild TBI

86

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MILD TRAUMATIC BRAIN

INJURIES “MTBI”

“TBI”

Traumatic Brain Injuries

NOT MILD!

87

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Concussion

• A concussion is a type of traumatic brain injury, or TBI, caused by a bump, blow, or jolt to the head that can change the way your brain normally works. Concussions can also occur from a fall or a blow to the body that causes the head and brain to move quickly back and forth.

• Health care professionals may describe a concussion as a “mild” brain injury because concussions are usually not life-threatening. Even so, their effects can be serious.

88

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Low Speed Crashes • The most important factors in whiplash-induced

concussion are angular acceleration,

flexion/extension tensions in the neck, and

intracranial pressure gradients.

Ommaya AK, Hirsch AE, Martinez JL: The role of

whiplash in cerebral concussion. 660804 197-

203, 1966.

89

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Head injury

• A head injury is any trauma that injures the scalp, skull, or brain. The injury may be only a minor bump on the skull or a serious brain injury.

Head injury can be either closed or open (penetrating).

• A closed head injury means you received a hard blow to the head from striking an object, but the object did not break the skull.

• An open, or penetrating, head injury means you were hit with an object that broke the skull and entered the brain. This usually happens when you move at high speed, such as going through the windshield during a car accident. It can also happen from a gunshot to the head.

Head injuries include:

• Concussion, the most common type of traumatic brain injury, in which the brain is shaken or the gradient sheer strains have occurred.

• Scalp wounds

• Skull fractures

• Head injuries may cause bleeding:

• In the brain tissue

• In the layers that surround the brain (subarachnoid hemorrhage and subdural hematoma )

90

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Symptoms:

Headaches, dizziness, memory loss, inability to concentrate, sleep disorders, irritability, lightheadedness, vertigo, neck pain, photophobia, tinnitus, easy distractibility, impaired comprehension, forgetfulness, impaired logical thought, difficulty with new or abstract concepts, easily fatigued, apathy, outbursts of anger, mood swings, depression, loss of libido, personality changes and intolerance to alcohol.

91

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PCS / MTBI Symptom Check List

Every firm should have their own PCS / MTBI check list.

Headaches, dizziness, memory loss, inability to concentrate, sleep disorders, irritability, lightheadedness, vertigo, neck pain, photophobia, tinnitus, easy distractibility, impaired comprehension, forgetfulness, impaired logical thought, difficulty with new or abstract concepts, easily fatigued, apathy, outbursts of anger, mood swings, depression, loss of libido, personality changes and intolerance to alcohol.

92

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Physical Symptoms

• Dizziness

• Periods of “blacking out” or seizures

• Problems with coordination of hands, feet, or legs (drop things

more often, balance problems)

• Stuttering or slurring

• Change in senses of smell or taste

• Blurry or double vision

• Ringing in the ears

• Headaches

• Fatigue

• More sensitive to bright light and/or loud noises

• Tingling or numbness in legs and arms

93

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Emotional Symptoms

• Feeling of sadness and depression

• Crying spells or weepiness

• Suicidal thoughts or intentions

• Decreased or increased emotion (circle one)

• Low motivation

• Decreased of increased sex drive (circle one)

• Decreased or increased appetite (circle one)

• Decreased interest in “fun” activities

• Difficulties with sleeping (getting asleep or staying asleep)

• Irritability / easily frustrated

• Feeling of anxiety or fear

94

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Aggressive Behavior After Head Injury

“TBI may go undiagnosed for months or years.

Frequency of Aggressive Behavior in the acute stage

ranges from 11% to 96% in TBI.

Patients with aggressive behavior were more likely to

have injuries to the frontal lobe.

Non-aggressive patients were more likely to have

diffuse brain injuries.”

“Clinical Correlates of Aggressive Behavior After TBI”,

Tateno et al, Journal of Neuropsychiatry and Clinical

Neurosciences, 2003;15:155-160

95

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Mild Traumatic Brain Injuries - MTBI

• Passengers rear ended at 10 mph have a 50% chance of sustaining a cerebral concussion.

• Lateral whiplash causes the greatest MTBI.

• Loss of consciousness is not a prerequisite for a concussion.

• Head trauma history could indicate a skull fracture - CT / MRI.

96

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TBI should resolve is 6

months –

If not – it is probably

permanent!

97

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Primary Portal of Entry for Many PI Cases – Doctor

of Chiropractic (DC)

• The DC is frequently the 1st Doctor a patient will see following a MVA.

• The DC is also the Doctor many patients see after months of symptoms without relief.

• Therefore, DC’s must understand acute and chronic Traumatic Brain Injuries!

98

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In The Clinic

• Pupils dilated?

• Spell WORLD backwards.

• Count backwards from 100 by 7’s.

• Remember 3 out of 5 random words 30 minutes later.

• Name, address, friends, telephone numbers.

99

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Traumatic Brain Injury &

Serum S-100

S-100 is a protein that is created after nerve cells in the

brain after injury.

90% with cranial injury had elevated S-100 protein

serum levels.

Ingebrigtsen et al., “The clinical value of serum-100

protein measurements in minor head injury”, a

Scandinavian multicenter study. Brain Injury

2000,14(12):1047-1055

100

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Diffuse Axonal Injury

• The acceleration / deceleration causes a shearing of

axons known as Diffuse Axonal Injury.

• Swelling and then regression (atrophy) of the axons.

• Possible hematomas.

101

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Testing:

• C T scan

• MRI (wait 3 months)

• EEG

• PET - positron emission tomography

• SPECT - single-photon emission CT

• BAER - brain stem auditory evoked responses

• Brain Mapping

• PSASAT - paced auditory serial addition test

102

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www.mildtraumaticbrainInjury.com

• Fill out web form to receive

• Free Check list PCS / MTBI

• Free firm case practice audit

• Law firm MTBI training platform

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Preparing for Trial

• Comprehensive Neurorehabilitation Evaluation

• A board-certified neurologist or neuropsychiatrist will determine the extent of the injury, and the client’s current and future needs

• Typically, includes a physical examination, family interviews, review of the medical records, neuropsychological testing and imaging studies

• The goal is to define the appropriate interventional services to foster maximal educational, occupational and social success following TBI

104

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Building your Client’s Case

• neuropsychological testing

• occupational therapy

• speech and language therapy

• physical therapy

105

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Records Review

• School, military and employment records may contain evidence of pre-morbid functioning levels

• Prior psychological testing results

• Military

• Employment

• Sports-related baseline tests for cognitive functioning - New

106

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Pediatric Cases

• For children or young adults, your expert may rely upon an educational evaluation to define the appropriate interventional services to foster maximal educational and social success

• In children, TBI will most likely compromise future learning and academic achievement, or social and behavioral development, as the child grows older.

• Your educational evaluation will include options for school placement, special education services, which may include intensive, one-on-one daily support, cognitive therapy, speak and/or learning programs may be recommended.

107

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Future Specials

• Medical follow-up to monitor progress and direct neurorehabilitation services

• The needs of the parent, guardian and/or caregiver must be considered, including ongoing support, family supportive psychotherapy, education, and training as to instructional or behavioral strategies, and periodic respite care

• Follow-up neurodiagnostic imaging to monitor cerebral atrophy and potential hydrocephalus ex vacuo – an abnormal buildup of cerebrospinal fluid in the ventricles of the brain, common in mild-moderate to severe TBI related to atrophy.

108

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Life Care Plan

• Your expert’s recommendations are typically then provided to a life-care planner

• Investigates ways to provide the recommended services within a comprehensive life care plan, and associated costs

• An economist will reduce the number to its present value

109

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Final Thoughts

• Stop, look and listen – to your client

• Ask the hard, intrusive personal questions

• Intra-family relations

• employment

• mood and personality changes

• TBI clients can tax your patience.

• Behavior which is seemingly annoying – repeated phone calls asking the same questions – may be signs and symptoms of the brain injury itself

• In the end, it’s worth it if you can fund a life care plan and do a service to a client in need.

110

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Bracing For The Siren Song:

Trying A Brain Injury Jury Trial

Deutsch, Kerrigan & Stiles, L.L.P.

New Orleans, Louisiana [email protected]

Presented By:

John Jerry Glas

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112

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• Separate Evidence & Testimony

Defense Trial

113

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Injury

Impairment

114

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Injury

(Neurosurgeon/ Neurologist)

Impairment

(Neuropsychologist)

C

A

U

S

E

D

115

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Frontal Lobe Injury

(Neurosurgeon/ Neurologist)

Impaired Memory

(Neuropsychologist)

C

A

U

S

E

D

116

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Impaired Memory

(Neuropsychologist)

117

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Impaired Memory

(Neuropsychologist)

P

R

O

V

E

S

Must have been a Frontal Lobe Injury!

118

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Impaired Auditory Memory

(Neuropsychologist)

P

R

O

V

E

S

C

A

U

S

E

D

Must have been a Frontal Lobe Injury, which must have caused the Impairment!

119

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Impairment

(Neuropsychologist)

Injury

120

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“[The neuropsychologist] was limited by the trial court

to the extent that she was allowed to testify regarding the

existence of a brain injury because she is not a medical

Doctor. She did testify that it was possible for a patient to

demonstrate neuropsychological deficits with negative

CAT scans, EMGs, MRIs, and ENGs as plaintiff did. She

explained that this occurs when the brain injury is caused

by nerve shearing which does not show up photographically

but does show up behaviorally. Contradicting Dr. Culver,

She further testified that loss of consciousness results from

an injury to the brain stem but plaintiff may have injured

some other part of the brain.”

- Bernard v. Lott, 666 So.2d 702, 704-705 (La. 4 Cir. 12/28/1995)

Limit

Neuropsychologists

122

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• Separate Evidence & Testimony

• Identify “Missing” Injuries

Defense Trial

123

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The Skull Hits First

124

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COUP

INJURY

Then The Brain Hits,

Causing The Coup Injury.

125

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The Skull Hits First

COUP

INJURY

126

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CONTRA-COUP

INJURY

There Is Movement

Away From The Opposite

127

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The Brain Hits,

Causing The Coup Injury.

COUP

INJURY

CONCRETE

128

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There Is Movement

Away From The Opposite,

COUP

INJURY

CONCRETE

129

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COUP

INJURY

CONCRETE

There Is Movement

Away From The Opposite,

130

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COUP

INJURY

CONCRETE

CONTRA-COUP

INJURY

Causing The

Contra-Coup Injury.

131

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CONCRETE

CONTRA-COUP

INJURY

COUP

INJURY

132

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• Separate Evidence & Testimony

• Identify “Missing” Injuries

• Establish Strengths

Defense Trial

133

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Cognitive Strengths (Average Range Or Higher)

Case # 1

• Mental Arithmetic Skills

• Auditory Attention/Working Memory

• Expressive Vocabulary

• Delayed Nonverbal Memory

• Right Hand Motor Speed

• Nonverbal Intelligence

• Spatial Planning

• Perception of Visual Details

• Visual-Construction Skills

• Nonverbal Reasoning

• Social Conventions & Judgment

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Cognitive Strengths (“Not A Concern”)

• Nonverbal Intelligence

• Fluid Reasoning

• Visual-Perceptual

Reasoning

• Processing Speed

• Visual Scanning

• Perceptual-Motor Speed

• Single-Word Receptive

Language

• Single-Word Expressive

Language

• Naming of Body Parts

• Comprehension of Oral

• Visual-Spatial Skills

• Graphomotor construction

• Reproduction of Block

Designs

• Visuomotor Precision

• Initial Learning

• Recall of Verbal Information

• Short-term Free Recall

• Long-term Free Recall

• Visual Memory

• Basic Categorical &

Conceptual Knowledge

Case # 2

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• Separate Evidence & Testimony

• Identify “Missing” Injuries

• Establish Strengths

• Identify Unaffected Functions

For “Damaged” Lobe

Defense Trial

136

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Cognitive Strengths Associated With Frontal Lobe

• Mental Arithmetic Skills

• Auditory Attention/Working Memory

• Expressive Vocabulary

• Delayed Nonverbal Memory

• Right Hand Motor Speed

• Nonverbal Intelligence

• Spatial Planning

• Perception of Visual Details

• Visual-Construction Skills

• Nonverbal Reasoning

• Social Conventions & Judgment

Case # 1

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Cognitive Strengths Associated With Frontal Lobe

• Nonverbal Intelligence

• Fluid Reasoning

• Visual-Perceptual

Reasoning

• Processing Speed

• Visual Scanning

• Perceptual-Motor Speed

• Single-Word Receptive

Language

• Single-Word Expressive

Language

• Naming of Body Parts

• Comprehension of Oral

• Visual-Spatial Skills

• Graphomotor construction

• Reproduction of Block

Designs

• Visuomotor Precision

• Initial Learning

• Recall of Verbal Information

• Short-term Free Recall

• Long-term Free Recall

• Visual Memory

• Basic Categorical &

Conceptual Knowledge

Case # 2

138

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• Separate Evidence & Testimony

• Identify “Missing” Injuries

• Establish Strengths

• Identify Unaffected Functions

For “Damaged” Lobe

• Address Poor Performances

Defense Trial

139

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Comparison of Performance

Memory

Testing

Performance

on 11/9/99

Performance

on 7/17/01

Performance

on 1/28/02

Auditory

Immediate

92 (30%)

94 (34%)

102 (55%)

Auditory

Delayed

94 (34%)

102 (55%)

105 (63%)

Visual

Immediate

84 (14%)

81 (10%)

91 (27%)

Visual

Delayed

88 (21%)

75 (5%)

94 (34%)

Working

Memory

76 (5%)

76 (5%)

83 (13%)

General

Memory

93 (32%)

86 (18%)

150 (50%)

Board No. 1

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Board No. 2

Memory

Testing

Performance

on 11/9/99

Performance

on 7/17/01

Performance

on 1/28/02

Auditory

Immediate

average

average

average

Auditory

Delayed

average

average

average

Visual

Immediate

average

average

average

Visual

Delayed

average

average

average

Working

Memory

low average

low average

low average

General

Memory

average

average

average

Comparison of Performance

141

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Board No. 3

COGNITIVE ABILITY

COMPARED TO PRE-ACCIDENT ABILITY,

PERFORMANCE WAS:

Worse Consistent Better

Auditory Immediate

Auditory Delayed

Visual Immediate

Visual Delayed

Visual Reproduction I

Visual Reproduction II

Working Memory

General Memory

142

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• Separate Evidence & Testimony

• Identify “Missing” Injuries

• Establish Strengths

• Identify Unaffected Functions

For “Damaged” Lobe

• Address Poor Performances

• Advocate For Accountability

Defense Trial

143

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Reduced Self-Control

No Control Over Impulse

(Disinhibition)

Disinhibition

(Irresistible Impulse)

144

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Methodology

Irresistible

Not Resisted

145

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Attack

Methodology

“The line between an irresistible

impulse and an impulse not

resisted is probably no sharper

than between twilight and dusk.”

U.S. v. Lyons, 731 F.2d 243, 248 (C.A. 5 (La) 1984),

quoting American Psychiatric Association Statement

On The Insanity Defense, 11 (1982) [APA Statement.

146

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Types Of

Impulses

Irresistible

Not Resisted

(involuntary conduct)

(voluntary conduct)

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Insanity

Defense

M’Naghten Test

Model Penal Code

17

14

Moral Incapacity 10

M’Naghten + Volition

Product Mental Illness

3

1

Cognitive Incapacity 1

Clark v. Arizona, 548 U.S. 735, 126 S.Ct. 2709, 165 L.Ed.2d 842 (2006)

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Need For

Supervision

“... I can tell you that [plaintiff] is going to break

those laws that will put him in some kind of

facility within a very short time if he lived

independently by himself. . .

I don’t think it’s his cognitive skills that are the

problem. I don’t think it’s his memory. . . I think

it’s his impulsivity and his lack of self-control

and his judgment that are damning him.”

Deposition of Beth Salcedo, MA, SLP, CCC, 6/10/09, p. 132, line 18 et seq

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What is plaintiff’s I.Q.?

Was plaintiff under influence of drugs, ETOH, meds?

Does plaintiff recall his behavior?

Did plaintiff understand physical act & consequences?

Could plaintiff distinguish between right & wrong?

Did plaintiff know “nature and quality” of the act?

Did plaintiff know behavior was illegal?

Did plaintiff believe behavior was immoral?

Did plaintiff feel guilty?

Did plaintiff plead guilty?

Establish

Knowledge

150

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Did plaintiff physically lose control over extremities?

Did plaintiff plan or organize before (premeditated)?

Was behavior self-endangering or self-defeating?

Would plaintiff have waited if officer there?

Did plaintiff lose all ability to control behavior?

How much disinhibition is required for the behavior?

How did you determine the impulse was irresistible?

Attack Volition

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“There is, in short, no objective basis for

distinguishing between offenders who

were undeterrable and those who were

merely undeterred, between the impulse

that was irresistible and the impulse not

resisted, or between substantial

impairment of capacity and some lesser

impairment.”

U.S. v. Lyons, 731 F.2d 243, 248 (C.A. 5 (La) 1984),

quoting Bonnie, Moral Basis Of The Insanity Defense,

69 ABA J. 194, 196 (1983)

Attack

Methodology

152

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• Separate Evidence & Testimony

• Identify “Missing” Injuries

• Establish Strengths

• Identify Unaffected Functions

For “Damaged” Lobe

• Address Poor Performances

• Advocate For Accountability

• Attack Medical Studies

Defense Trial

153

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Size Of

Study

World

Population 6,623,798,795

Australia

Population

20,434,176

Study

Population

122

Infants

27

Mild

4

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American Children

Under The Age Of 5

20,000,000

Cases

Of TBI

50,000

Study

Population

122

Infants

27

Mild

4

Size Of

Study

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Internet Abstract

156

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Exclusion Criteria

Exclusion Criteria

• Previous TBI

• Pre-Existing Physical,

Neurologic, Psychiatric, Or

Development Disorder.

• Penetrating Head Injury

• TBI Caused By Child Abuse

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Inclusion Criteria

Inclusion Criteria

• Age at injury (3 -13)

• Documented evidence of TBI

including period of altered

consciousness

• Ability To Complete Cognitive

Evaluations

• Completions Of All Three

Evaluations

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Prior Study

Exclusion Criteria

Earlier Study:

Inclusion Criteria

Inclusion Criteria

• Age at injury (2-7)

• Documented evidence of TBI

including period of altered

consciousness

• Medical Records Sufficient To

Determine Injury Severity

• Ability To Complete Cognitive

Evaluations

• Completions Of All Three

Evaluations

• English As First Language

• Parents Competent With

English

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Classifications

160

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Classification Of

Plaintiff

161

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Control Group

Performance

162

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Did Better On 5/6 Tests !

Control Group

Performance

163

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Lower

Lower

Control Group

Performance

164

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Within Standard Deviation!

Control Group

Performance

165